Inquest into the Death of Charles Raymond Gamble
Deceased
Charles Raymond Gamble
Demographics
30y, male
Date of death
2003-05-06
Finding date
2004-10-14
Cause of death
Ligature compression of the neck (hanging)
AI-generated summary
Charles Raymond Gamble died on 6 May 2003 by ligature compression of the neck while in lawful custody in an AIMS transport vehicle travelling from Perth Watch-house to Perth Central Law Courts. He had recently confessed to sexual offences against juveniles, had a history of suicide attempts, and was known to be at acute risk of self-harm. He was found hanging from his own shoelaces tied to a padlock on an escape hatch. The coroner found multiple systemic failures: AIMS officers failed to read warning documentation despite 'At Risk' stamps; police returned his boots with laces despite knowing he was high-risk; the padlock was an obvious hanging point; prisoners were left unsupervised in the vehicle; monitoring cameras were inadequate; and critical alert information failed to transfer between police and justice department systems. The coroner made recommendations regarding prisoner safety in transport, documentation systems, and inter-agency communication.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Failure by AIMS officers to read and act upon 'At Risk' warning documentation
- Return of deceased's boots with laces despite known self-harm risk
- Accessible padlock on escape hatch used as hanging point
- Inadequate monitoring cameras that did not cover the hanging point
- Deceased left unsupervised in vehicle on two occasions before departure
- Failure to transfer alert information from TOMS system to AIMS before transport
- Movements List provided to AIMS contained no alert despite high-risk status
- Inadequate handover communication between police and AIMS officers
- Recent admission to sexual offences creating acute psychological distress
- Previous suicide attempt by hanging with belt on 3 May 2003
Coroner's recommendations
- AIMS Corporation should ensure no prisoner leaving East Perth lock-up has items capable of being used for self-harm, and in particular should not return footwear to prisoners being transported
- AIMS Corporation should create effective management systems to ensure staff at East Perth lock-up perform duties appropriately on a regular basis
- Department of Justice should create effective management systems to ensure AIMS staff at East Perth lock-up perform duties appropriately on a regular basis
- The adequacy of close circuit monitoring within all AIMS transport vehicles should be assessed with consideration of audio monitoring
- Police Service should draft a policy for completion of Movements Lists provided to AIMS, ensuring reserve staff have access to P10A documentation
- Police Service should develop improved computer systems for recording warnings on P10A forms and draft policy requiring officers to record dates of self-harm incidents
- Department of Justice and Police Service should ensure at-risk information is immediately communicated between systems, developing a person-in-custody management system with information transfer protocols
Full text
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Source and disclaimer
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